Defending the right to health during Sudan's civil war
Authors: Fatima Elbasri Abuelgasim Mohammed, Maria Inês Francisco Viva, Wafa Awadalla Gasmalla Awadalla, Osman Kamal Osman Elmahi, Daniel Wainstock, Poorvaprabha Patil
Journal: The Lancet Global Health (2023)

The Sudanese health system was strained before the outbreak of armed conflict between the Sudanese Armed Forces (controlled by the Sudanese Government) and the Rapid Support Forces. Sudan has one of the highest maternal mortality rates in the world (295 deaths per 100 000 livebirths) and a severe shortage of health-care workers with only four doctors for every 10 000 people.1UN Office for the Coordination of Humanitarian AffairsSudan situation report.https://reliefweb.int/report/sudan/sudan-situation-report-9-nov-2020-enarDate: Nov 9, 2022Date accessed: May 29, 2023Google Scholar, 2Gavi The Vaccine AllianceSudan conflict leaves health system in 'total collapse'.https://www.gavi.org/vaccineswork/sudan-conflict-leaves-health-system-total-collapseDate: May 2, 2023Date accessed: May 29, 2023Google Scholar Health-care workers faced substantial challenges and violations of their rights before the conflict, such as low pay and violent attacks, including the killing of health-care workers and humanitarian aid workers by the military.3Osman M Alassam MN Military attacks on health workers in Sudan.Lancet. 2022; 3991045Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Although faced with major challenges health-care workers have been at the forefront of the revolution, pushing for a fairer and more democratic Sudan.4ALJAZEERASudan doctors targeted with threats and smear campaigns.https://www.aljazeera.com/amp/news/2023/5/9/sudan-doctors-targeted-with-threats-and-smear-campaignsDate: May 9, 2023Date accessed: May 29, 2023Google Scholar Today, as the conflict continues, it is preventing health-care workers from doing their jobs and saving lives. During the war, an estimated 70% of hospitals in Khartoum and nearby states have had to cease operations as a result of the ongoing conflict.2Gavi The Vaccine AllianceSudan conflict leaves health system in 'total collapse'.https://www.gavi.org/vaccineswork/sudan-conflict-leaves-health-system-total-collapseDate: May 2, 2023Date accessed: May 29, 2023Google Scholar Attacks on health-care workers and facilities have been committed by both sides of the conflict: health facilities have been looted by the Rapid Support Forces and the Sudanese Armed Forces have threatened doctors, accusing these clinicians of being traitors for treating militia members.4ALJAZEERASudan doctors targeted with threats and smear campaigns.https://www.aljazeera.com/amp/news/2023/5/9/sudan-doctors-targeted-with-threats-and-smear-campaignsDate: May 9, 2023Date accessed: May 29, 2023Google Scholar The conflict is also affecting access to health care for all Sudanese citizens, leading to the deterioration of individuals with existing health conditions as well as increasing the risks of death and disease. Sudan already faced substantial challenges with hunger and malnutrition due to the rapid inflation of food prices. Moreover, Sudanese food stability relies on successful agricultural yield; this is threatened by intense variation in rainfall, a phenomenon aggravated by climate change, and presents a severe threat to this stabilisation. Sudan had more than 3 million malnourished children before the conflict began.6UN World Food Program USAWhat's happening in Sudan? Explainer on the current conflict and its effects on humanitarian aid to civilians.https://www.wfpusa.org/articles/whats-happening-sudan-explainer-current-conflict-effects-humanitarian-aid-civilians/Date: May 4, 2023Date accessed: May 29, 2023Google Scholar The inability to ship food into the country, combined with the destruction of the Samil factory during the war, has catastrophically affected child nutrition as the Samil factory was providing 60% of the ready-to-use therapeutic food designed to treat children with acute malnutrition in the country.7UNICEFAnother bitter blow for children in Sudan.https://www.unicef.org/press-releases/another-bitter-blow-children-sudan-1#:~:text=Geneva%2C%2012%20May%202023%20%E2%80%93%20%E2%80%9C,Use%20Therapeutic%20Food%20(RUTF)Date: May 12, 2023Date accessed: May 29, 2023Google Scholar Moreover, various Government assets have been seized by the Rapid Support Forces, including the Sudan Public Health Laboratory. The occupation of the laboratory is preventing the testing of laboratory samples and it risks the potential mishandling of infectious specimens, including those containing poliovirus, cholera, and measles.8CNNWHO warns of 'biological risk' after Sudan fighters seize lab, as violence mars US-brokered ceasefire.https://amp.cnn.com/cnn/2023/04/25/africa/sudan-evacuations-ceasefire-intl/index.htmlDate: April 26, 2023Date accessed: May 29, 2023Google Scholar Additionally, the damage to crucial water and sanitation infrastructure is increasing the likelihood of diarrhoeal disease.8CNNWHO warns of 'biological risk' after Sudan fighters seize lab, as violence mars US-brokered ceasefire.https://amp.cnn.com/cnn/2023/04/25/africa/sudan-evacuations-ceasefire-intl/index.htmlDate: April 26, 2023Date accessed: May 29, 2023Google Scholar Since April 15, 2023, 730 people have been killed, 5500 have been injured, more than 345 000 people have migrated, and 1 million have been internally displaced due to the conflict in Sudan.5UN Office for the Coordination of Humanitarian AffairsSudan: clashes between SAF and RSF - flash update no. 14.https://reliefweb.int/report/sudan/sudan-clashes-between-saf-and-rsf-flash-update-no-14-28-may-2023Date: May 28, 2023Date accessed: May 29, 2023Google Scholar As health-care professionals directly affected by the conflict, and also as those responsible for improving the health of those in Sudan, we strongly disagree with the Sudanese Armed Forces and Rapid Support Forces assertions that they have no intention to stop the war unless one side takes full control, declaring that the war is an internal affair.9ALJAZEERA Centre for StudiesThe conflict between the Sudanese Army and the Rapid Support Forces: context and trends.https://studies.aljazeera.net/en/policy-briefs/conflict-between-sudanese-army-and-rsf-context-and-trendsDate: April 19, 2023Date accessed: May 29, 2023Google Scholar We implore both sides of this conflict to agree to a long-term ceasefire and facilitate access to life-saving humanitarian aid in Sudan. The fact that an absence of humanitarian corridors and opening of the air space meant that humanitarian agencies delivered only 53 trucks of life-saving supplies (a third of the planned amount) is completely unacceptable.5UN Office for the Coordination of Humanitarian AffairsSudan: clashes between SAF and RSF - flash update no. 14.https://reliefweb.int/report/sudan/sudan-clashes-between-saf-and-rsf-flash-update-no-14-28-may-2023Date: May 28, 2023Date accessed: May 29, 2023Google Scholar Neighbouring countries and the global community must not forget about Sudan, and they should continue to advocate for further negotiations on a long-term cease-fire, opening safe roads to humanitarian aid, and holding both the militia and armed forces accountable for human rights violations. We call on WHO to publicly continue to report on the attacks on health workers and facilities, deliver life-saving medical supplies including oxygen and medication, and to prioritise the accessibility of health systems and rehabilitation. As health-care leaders and those in affected communities, we want to be at the forefront of any response. We want donors to support us in both conducting life-saving activities including training citizens on essential life support, mobilising community leaders to provide shelters for those who have lost their houses and increasing all citizens' awareness about combating infectious diseases. We hope that academic institutions around the world will partner with and support Sudanese health-care workers and researchers to lead and generate research on the effects of the war on vulnerable groups including children, adolescents, women, immigrants, and internally displaced people. Finally, we call for the global health community to amplify the voices of Sudanese researchers, clinicians, and communities, to maintain focus on the ongoing conflict in Sudan, and ensure that the right to health of all Sudanese citizens is realised despite the current conflict. We declare no competing interests. We would like to thank Mike Kalmus Eliasz for reviewing our manuscript.